Weather, incorrect procedure, probable causes of Lao Airlines QV 301 crash

Source:Xinhua Published: 2014-11-28 14:56:01

A sudden change in weather conditions and the flight crew's failure to properly execute procedure have been identified as the probable causes of the crash of Lao Airlines flight QV 301, according to a final report on the accident released Friday.

The report, released by the Lao Ministry of Public Works and Transport, was the product of an investigation by officials from Laos, France's civil aviation authority BEA (appointed by aircraft manufacturer ATR) and AAIB (Air Accidents Investigation Branch) Singapore. The report states that QV 301 crashed in bad weather while attempting a go-around after a failed landing attempt.

The flight data recorders recovered from the crash revealed that the flight crew set an altitude of 600 feet as the aircraft's minima, or altitude at which visual references with the ground are analyzed as sufficient or insufficient for landing.

The flight crew's minima of 600 feet was lower than the published minima of 990 feet and the incorrect height of 645 feet as published in the JEPPESEN Chart at that time.

After aborting the aircraft's approach at an altitude of around 595 feet, the flight crew executed a right turn instead of a nominal climb as dictated by the airport's VOR/DME missed approach procedure.

When the flight crew realized that the aircraft's altitude was too low, the Pilot Flying overreacted, leading to a high pitch attitude of 33. When the plane's altitude reached the minimum value of 60 feet, the aircraft's roll had reached approximately 37 to the right.

During the plane's flight, there was a local thunderstorm approaching the airport from the Southwest. According to the report, the sound of heavy rain striking the plane was audible on the Cockpit Voice Recorder (CVR).

The report found that the engines were operating at nominal power until the end and that the flight crew were all licensed and qualified. No anomalies were reported following an investigation of the airport's ground equipment.

The Pilot in Command, 57 year old Yong Som from Cambodia, had logged over 5,600 flying hours, including 3,200 hours in the ATR- 72. The flight's First Officer, 22 year old Soulisack Hongvanthong, had already logged more than 400 flying hours after finishing his training in France in the preceding months.

The report outlined a series of safety recommendations made to both the airline operator and regulatory authority. The recommendations include a review of the reporting system for flight crew to report operations related issues, such as errors in the JEPPESEN chart or in other future charts.

The recommendations also include training crews in the effects of somatogravic illusions (where human sensory input does not match the aircraft's actual movement) which were highlighted as a possible contributing factor to the accident.

Lao Airlines flight QV 301 crashed on Oct. 16, 2013 on a flight between Lao capital Vientiane and Pakse. The flight carrying 44 passengers and five crew hit the bank of the Mekong River, several kilometers away from its final destination of Pakse International Airport.

There were no survivors of the flight which claimed the lives of two Chinese nationals.

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